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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --- ---- �- �------------ -- -- ---- <br /> (Complete in Triplicate) Permit No. <br /> This Permit Expires 1 Year From Date Issued Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No 549 and existing Rules and Regulations. <br /> JOB ADDRESS/LOCATION .- --=I _ _ l <br /> r �""`""� - CENSUS TRACT -------------------------- <br /> Owner's Name --- -- ---Phone <br /> Address ---------------- -/X-f �'F ' <br /> �A� <br /> ------------------ City ---- -------- --,------------- --------------------------------------------- <br /> Contractor's <br /> ----------------- - - --Contractor's Name --------------- ------------- ---------------------------- --------------------- -------license # --- -- ----------------- Phone -----------------------••----- <br /> Installation will serve: Residence ❑ Apartment House E] Commercial ❑Trailer Cvart JW <br /> Motel ❑ Other <br /> Number of living units:._.------ Number of bedrooms __Jr-------Garbcge Grinder ------------ Lot Size ..............._____ <br /> Water Supply: Public System and name ________________________ ___Private ❑ 1 <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam <br /> Hardpan j Adobe.E] Fill Material ------------ If yes, type ---------------------------- <br /> (PI'ot plan, showing size of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.) p4 ' <br /> NEW INSTALLATION: (No septic tank or-seepage pit permitted if public sewer is available within 200 feet,) �N <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[] Size------------------------------------------------ Liquid Depth -_--------------------•_-- Gl <br /> Capacity .e�_ - ----------_ Type 114/--------- Material_ef-W---_----- No. Compartments -.;L_----------- <br /> Distance <br /> __ _Distance to nearest: Well _ `Q_f-------------------------Foundation - Prop. Line _ <br /> LEACHING LINE ] No. of Lines _--/------------------- length of each line.---_0-------------._-__- Total Length ko-------------•-------- <br /> 'D' Box ----_I------ Type Filter Material ____________________Depth Filter Material <br /> ---------=----------------------- <br /> Distance to'nearest: Well ________________________ Foundation ____ Property Line <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No ❑ <br /> Water Table Depth ----------------------------------- ------------Rock Size + <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line _.---_---------------- <br /> REPAIR./ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date <br /> Septic Tank (Specify Requirements) __._-______ _____.__________________________ <br /> Disposal Field (Specify Requirements) - . <br /> { <br /> ----------------------------------------------------------- <br /> - ----------------------------------------- <br /> ----------------------------- <br /> --------------- ----------------- <br /> (Draw existing and required addition on reverse side) <br /> s <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to bgome subject to Workman's Compensation laws of California." <br /> Signed ._.. ----- Owner <br /> By --- - --------- ---------------------------- --- ----------------------------- Title ---------------- ------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- DATE --- �"gip------------------- <br /> ----------------------------------------------------- <br /> BUILDING PERMIT ISSUED ----------------i-------------------------------------------------- -------------- -------DATE <br /> ADDITIONAL COMMENTS <br /> -------------------------------------------------------------------------------------------------------------------------------------- --------- --- --------- <br /> --------- ---------------------------------------------------------------------------------------------------------------------------------------------------..-------- -------- <br /> -- ------------------------ <br /> - -----=------- <br /> Final Inspection by: - - - -- -:- -------- ----- Dated'-2f � ' <br /> [ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> +I <br /> E. H. 9 1-'6$ Rev. 5M <br />